By JONATHAN L. PENNINGTON, NICOLE PENNINGTON, BETH DELANEY, AND MARY BETH BLANKENSHIP
What do maternity nurses and first responders have in common? Both need to respond immediately to birthing babies. What better way to prepare than training and practicing on a maternity simulation mannequin that actually gives birth? That is exactly how firefighter emergency medical technicians trained during a certification refresher course at the Ashland (KY) Fire Department (AFD). The Ohio University-Southern Campus (OUSC) associate degree nursing program and the AFD collaborated on performance-based training for firefighter/EMTs. The collaboration allowed firefighters to don gloves and assist a simulation mom through birthing. Participants felt the training provided hands-on clinical experience that better prepared them to deliver a baby in the field as well as deal with possible complications, such as a prolapsed cord and breech presentation.
WHY PERFORMANCE-BASED TRAINING?
The educational approach of maternity-newborn simulation focuses on using mid- to high-fidelity simulation scenarios. Maternity simulation is a technique of reenacting or replicating routine or critical clinical events involving a pregnant woman or recently delivered newborn. Obstetrical simulation’s overarching goal is to improve the quality and safety of care for women and newborns.1
You can specify and schedule curricula in advance when it makes the most sense in the continuum of training rather than leave it to the chance occurrence of learning during everyday patient care. Performance-based simulation provides repeated practice of a wide range of clinical scenarios. Because simulated scenarios are completely replicable and highly standardized, it is much easier to review and evaluate performance. You can videotape and review trainees’ simulation experiences to further facilitate learning and permit assessment of process, style, and outcome.
When students experience good simulation before real-life experiences, they develop self-confidence. To achieve this, simulation works best with real-life experiences. Advances in simulation and virtual technology now offer excellent adjuncts to “live” education, reducing the barriers associated with limited experiences. Technology provides efficient, safe, and effective alternatives to expand clinical teaching opportunities.
Performance-based simulation training is a novel approach that uses higher-order thinking skills. Simulation-based training challenges emergency medical technicians and firefighters to develop cognitive, technical, and behavioral skills by using mannequins, working medical equipment, and humans.
During scenarios, students must use their knowledge, analyze and synthesize factors contributing to the crises, and evaluate their actions’ effects. Feedback indicates that simulation-based training programs are more pertinent to and better accepted by adult learners than traditional programs.2
The instructional methodologies used in simulation-based training programs are more in line with the tenets of adult learning. It is often difficult to provide first responders with experiences that match classroom content. Performance-based simulations of real-life care that relate directly to classroom material allow students to build patient care skills while applying theoretical knowledge in a controlled setting. Such simulations reinforce material learned in lectures and promote an active learning environment.
The birthing simulator provides students with a complete firsthand birthing experience before, during, and after delivery with the ability to endure related complications.3 With this particular simulator, responders get hands-on experience in auscultating fetal heart tones, assisting with the birth, assessing the newborn in transitioning to extrauterine life, and providing care to mom after delivery.
Using realistic high-fidelity interactive patient simulators was pioneered in anesthesia in the mid-1980s.4 However, only recently has simulation technology become more widespread, and its full educational potential has not yet been realized. Real educational innovations don’t come along too often. In the mid-17th century, Moravian educational reformer John Comenius decided that a picture truly was worth a thousand words and added illustrations to textbooks. It took another two centuries for distance learning, when the Chautauqua Methodist School instituted mail-course instruction. And now, two centuries later, virtual reality may become the next educational innovation.(4)
Research regarding good teaching shows the importance of incorporating educational practices with certain pedagogical principles that, when used consistently, result in increased learning and satisfaction. Overall studies show that simulation activities tend to increase students’ self-confidence in their critical thinking and problem-solving abilities.5
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COLLABORATION AND METHODOLOGY
The training developed for the AFD followed the 1994 curriculum for EMT-B refresher training established by the U.S. Department of Transportation and the National Highway Traffic Safety Administration. The AFD collaborated with OUSC’s associate degree nursing program to provide instruction delivery and to use a birthing simulator for didactic and hands-on training.
A pretest was administered prior to the training to assess responders’ current knowledge level; the overall average score was 88 percent. The pretest consisted of multiple choice questions created by the OUSC nursing faculty based on curriculum objectives for emergency responders and firefighters. The 88 percent score for a refresher course was not surprising because training in this area is required biannually. The goal of a refresher course using advanced teaching modalities is to increase retention of content delivered and provide performance-based learning to increase skills performance.
Following analysis of the pretest results, the OUSC nursing faculty created the didactic instruction specific to the learning needs of firefighters and emergency medical technicians, which included lecture content delivered by a nursing professor using both PowerPoint® and a classroom response system to engage class participants. The lecture included specific information covering anatomy, physiology, labor, birth, and birthing complications. Integrated into the lecture, all participants used a device called a “classroom responder” when prompted.
A classroom response system (also referred to as “audience feedback” or “clickers”) provides students with a handheld remote to respond to the instructor’s questions. This technology is becoming especially popular among instructors of large lecture classes.6 Research indicates that students find this type of technology easy to use and perceive it as enjoyable, beneficial to learning, and encouraging to class attendance.
Throughout the instruction, the instructor presents questions on the screen; the participants answer them by entering their choice with the classroom responder. This provides immediate feedback as to whether the delivered content is being understood by all. The instructor then shows a bar graph of correct answers following each question. When the score was below 100 percent, the instructor reemphasized the point with further discussion. Participants stayed engaged throughout the lecture portion knowing that if they did not respond to a question, they could be identified through the software reporting system. It became a very competitive process as participants competed to see who had the highest score on the report.
Following the didactic portion of the training, the performance-based skills were initiated. The instructor divided the class by their engine companies. Each engine company was given a scenario to review and then perform with the birthing simulator. While one engine company worked with the simulator, the other participants critiqued each simulation and provided feedback after each simulation was completed. Scenarios included emergency responses where the birth would not wait until they could transport to the hospital and delivery had to take place in the field. Each engine company was given very different situations, including delivering twins, assisting a precipitous delivery, dealing with excess bleeding following delivery, and resuscitating the newborn following delivery.
Responders indicated that even though they previously had learned the procedure to deal with all of these situations, actually performing these skills helped them tremendously. All reported that they felt that they could deliver a baby in an emergency situation if needed and felt better prepared since they had now delivered a baby, even if it was not real. Each engine company delivered and named a “baby” following each simulation. Some of the firefighters commented that it seemed most of their interactions with obstetrics in the field came from mothers who did not know how far along they were, had not been taking prenatal vitamins, and had not been to a physician for regular checkups. The designed simulations allowed them to have a controlled experience in assessing the situation’s true nature and to apply different acceptable techniques to solutions for the mother and the baby.
A posttest was administered at the end of the class. There was a 98.4 percent proficiency level and overwhelming satisfactory skills performance by every engine company. The participants’ engagement in the training was incredible.
IMPLICATIONS FOR PRACTICE
Simulation plays an increasingly important role in performance-based education and in the competency evaluation of emergency medical technicians and firefighters. There is a need to develop theory-based simulation protocols that focus on critical components of emergency responders; the development of rigorous and reproducible performance-based protocols allow their use for competency evaluation and educational research.7
Partnering with other community agencies is one strategy to increase opportunities for performance-based simulation training. Resource sharing can give firefighter/EMTs additional educational experiences. Other examples of patient simulation include adult, neonatal, and pediatric simulators. Collaborating and using simulators from community partners is a win-win situation. Current simulation technology is sufficiently realistic as a surrogate for actual patient care.8
The training the AFD provided can easily be replicated by other emergency response institutions. You can use performance-based simulation in the fire service with other simulators such as emergency apparatus driving, incident command, and hazardous materials response. Providing firefighters and emergency responders with more real-life situations better prepare them for the responses that they will have to make. Our communities expect well-trained, educated responders.
ENDNOTES
1. Gardner, R., “Simulation and simulator technology in obstetrics: past, present and future. Expert Review of Obstetrics & Gynecology.” Arcadia Search Complete Database, 2007.
2. Bartlett, C., et al, “Does simulation training improve communication with a simulated patient during an obstetric emergency?” Journal of the Society for Simulation in Healthcare; 2006 1(3), 191.
3. Yaeger, K., and J. Arafeh, “Making the move: from traditional neonatal education to simulation-based training.” Journal of Perinatal & Neonatal Nursing. 2008; 22(2); 154-158.
4. Benner, P., “Using the Dreyfus model of skill acquisition to describe and interpret skill acquisition and clinical judgment in nursing practice and education.” Bulletin of Science, Technology & Society, 2004; 24; 188-199.
5. Chickering, A., and Z. Gamson, “Seven principles of good practice in undergraduate education.” The Wingspread Journal, 1987.
6. MacGeorge, E., et al, “Student evaluation of audience response technology in large lecture classes.” Education Technology Research & Development; 2008, 56(2), 158-145.
7. Kinkaid, J., J. Donovan, and B. Pettitt, “Simulation techniques for training emergency responders.” International Journal of Emergency Management; 2003; 1(3) 238-246.
8. Grossman, C.C., and D.B. Hudson, “Rating students’ technology generated clinical decision making scores.” Nurse Educator; 2001; 26(1), 5-6.
JONATHAN L. PENNINGTON, CFO, MIFireE, CSP, is a battalion chief with the Ashland (KY) Fire Department and coordinates the department’s special operations and EMT programs.
NICOLE PENNINGTON, MSN, RNC, is an assistant professor and the associate director of the nursing program at Ohio University-Southern Campus (OUSC).
BETH DELANEY, RN, MSN, ARNP, is an assistant professor of nursing at OUSC.
MARY BETH BLANKENSHIP, RNC, MSN, ARNP, is an assistant professor of nursing at OUSC.
